Metabolic and Bariatric Surgery

Directions

The Madigan General Surgery Clinic is located in Madigan Army Medical Center and can be reached by taking I-5 Exit 122 and turning onto Beaumont Avenue into the Medical Mall Purple Parking Lot. The General Surgery Clinic is located on the second floor of the Medical Mall.

About

Our accredited center for Metabolic and Bariatric Surgery Services is supported through the General Surgery clinic at Madigan. We provide expert consultative inpatient and outpatient healthcare services for patients suffering from metabolic and weight-related medical conditions. Our ability to provide this care is facilitated by our state-of-the-art health care facility and our providers’ first rate education, research and process improvement programs. We look forward to working with you to meet your healthcare goals and thank you for choosing Madigan Army Medical Center.

Patients seen in the General Surgery Clinic are those referred from their primary care provider.

The Madigan General Surgery-Metabolic and Bariatric Surgery Service offers the following elective surgeries:

Types of Bariatric Procedures

Biliopancreatic Diversion with Duodenal Switch (DS)

 

The Biliopancreatic Diversion with Duodenal Switch (DS) procedure involves removing a portion of the stomach along the outer margin, leaving a sleeve of stomach with the pylorus (similar to a sleeve) and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that the pancreatic and bile drainage is bypassed. The near end of the “alimentary limb” is then attached to the beginning of the duodenum. The common limb is 1.5 m (150 cm) long, regulates the amount of protein, fat, and fat-soluble vitamins absorbed. Micronutrient deficiencies are always a risk, especially the fat soluble vitamins (ADEK). It is important to take multivitamins daily to avoid deficiencies.

Pros:

• Patients are able to eat larger meals than with a sleeve or a Roux-en-Y Gastric Bypass procedure
• This procedure can produce the greatest excess weight loss because it provokes the greatest stimulation of incretins and intestinal hormones, decreasing hunger sensation
• Greatest rate of Diabetes resolution
• Long-term maintenance of weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen
• Lowest rate of weight regain

Cons:

• For all malabsorptive procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. In time this side effect improves (avoid eating fats, and sugars)
• Abdominal bloating and malodorous stool or gas may occur (avoid sugars and legumes)
• Close lifelong monitoring for protein malnutrition, anemia, and bone disease is recommended; lifelong vitamin supplementation is required
• Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder; this is a risk for every Bariatric/Metabolic procedure

Gastric Band Procedure

The gastric band procedure involves placing an adjustable band around the upper part of the stomach (the band is filled with saline fluid through a port that lies just underneath the skin). The change functions to provide a sensation of fullness after a small meal and reduces the feeling or hunger between meals.

A band is placed around the top of the stomach to create a small pouch that limits food intake. A small port is affixed inside the body that allows the band to be adjusted to make the pouch smaller or bigger.

Pros:

• No re-sectioning of the stomach
• No vitamin or mineral deficiencies due to malabsorption
• There are no reconnections of intestines, no stapling, and no removal of the stomach
• No malabsorption

Cons:

• Less weight loss than Gastric Bypass and Sleeve Gastrectomy (Hutter et al)
• Gastric Band may slip or erode into the stomach, resulting in additional operations
• While not common, excessive vomiting may result if eating food too quickly, taking large bites of food, drinking fluids with meals or snacks, or eating dry, tough, or sticky foods
• Having to have the Gastric Band adjusted to maintain weight loss
• Risk of mechanical failure and/or leaking of port or tube
• Requires many more follow ups than Gastric Bypass and Sleeve Gastrectomy

*We currently do not offer placement of gastric bands, but are able to provide the full spectrum of follow up care for patients that have one in place, including surgical management of complications.

Roux-en-Y Gastric Bypass

The Roux-en-Y Gastric Bypass is the gold standard Bariatric/Metabolic procedure. Food bypasses the initial part of the small intestine where many micronutrients (minerals and vitamins) are absorbed. This helps to achieve weight loss, but also increases risk for micro-nutritional deficiencies. Patients are required to take life-long nutritional supplements that usually prevent these deficiencies. Gastric Bypass may cause dumping syndrome because food moves quickly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and occasionally diarrhea after eating, especially carbohydrate rich foods.

A small stomach pouch, about the size of an egg, is created using a surgical stapler. This small pouch restricts the amount of food intake by only allowing a small amount of food to be eaten at one time. This restrictive component allows for caloric intake restriction and plays an important role in the initial weight loss seen after this procedure for the first 6 months. The small bowel is divided, with a surgical stapler, about two feet from the stomach. One end of the small intestine is brought up to the new stomach pouch. The small intestine that is still connected to the separated stomach is reconnected to the intestinal tract. The rearrangement of the intestinal tract causes food to travel faster to the distal small bowel stimulating the release of intestinal hormones that communicate with your brain to promote satiety, decrease hunger sensation, delays stomach emptying. It also stimulates the pancreas to release insulin in response to carbohydrate (sugars) intake. These intestinal hormonal changes lead to sustained weight loss for a long period of time.

Pros:

• Reversible, Sustainable weight loss with limited dietary compliance
• Best procedure for to treat GERD
• No implantation of foreign object like with the band procedure
• Better weight loss and resolution of diabetes vs sleeve at 5 years post-surgery
• Offers benefit of both restrictive and malabsorptive
• Gold standard Bariatric procedure

Cons:

• Risks of nutritional deficiencies without adequate diet and multivitamins intake
• Malabsorption can lead to anemia (Iron, B12)
• At risk for dumping syndrome, potential for leaks along the staple lines, internal hernia risk

 

Sleeve Gastrectomy

(Partial Gastrectomy, Vertical Sleeve Gastrectomy, and Gastric Sleeve)

This procedure is only performed on the stomach and does not involve the intestines. It consists of making the stomach, which looks like a pouch, into a long narrow tube; hence the name "sleeve". The Sleeve Gastrectomy removes two thirds of the stomach, which provides a quicker sense of fullness and decreased appetite. The smaller stomach restricts food intake by allowing only a small amount of food to be consumed at one time.

The sleeve is created with a surgical stapler following along the curve of the stomach. After the new stomach is created, the remaining stomach is removed. The outlet of the stomach (pylorus) remains and allows for the normal process of stomach emptying.

Pros:

• Does not require the implantation of a foreign object, such as the Gastric Band
• The procedure decreases the size of the stomach and removes the portion of the stomach where ghrelin, a hormone that controls hunger sensation, is produced
• Likely no vitamin or mineral deficiencies because there is no malabsorption; however you are still required to take multivitamins, since the decreased food intake may limit the vitamins and nutrients you get from your diet
• No rerouting of the intestines
• Less long-term maintenance than the Gastric Band

Cons:

• Weight loss less than the Roux-en-Y Gastric Bypass at 5 years post-surgery
• The risk of developing GERD de novo after this procedure is about 42%. (Castagneto et al 2018)
• Not a good Bariatric surgery option for patients with a GERD and/or hiatal hernia
• Vomiting or discomfort may result if food is eaten too quickly, taking large bites of food, drinking fluids with meals or snacks, or eating dry, tough, or sticky foods
• There is a potential for leaking/bleeding along the staple line
•  

Stomach Intestinal Pylorus Sparing Surgery (SIPS)

 
The stomach intestinal pylorus-sparing procedure (SIPS) involves the creation of a 300-cm common channel with a single-anastomosis duodenal enterostomy. Source: Courtesy of David Baker, Bariatric Medical Institute (BMI) of Texas, San Antonio.

The Single Anastomosis Duodenal Switch, also known as: Stomach Intestinal Pylorus Sparing Surgery (SIPS), or the Single Loop Duodenal Switch, is similar to the duodenal switch procedure, except that the small intestine is transected at one point instead of two. The majority of the stomach is removed, like the Sleeve Gastrectomy, but basic stomach function remains the same. Also, roughly half of the upper small intestine is bypassed, which moderately decreases the calorie absorption. Weight loss is achieved both through restriction of food consumption and decreased absorption. There is also increased stimulation of gastrointestinal hormones that cause increased satiety, decreased hunger sensation which results in good long-term weight loss maintenance.

 

Pros:

• Unlike other gastrectomies, the vertical sleeve gastrectomy leaves the pyloric valve in place. This valve controls the movement of food into the small intestine. By keeping this valve intact, it removes the patient’s risk of dumping syndrome and complications such as blockages and stoma closure.
• By preserving the pyloric valve the procedure has been perfected to prevent blood glucose spikes. (These sugar spikes can promote hunger and hence increased eating).
• Similar weight loss to Duodenal Switch, and greater than the Gastric Bypass and Sleeve Gastrectomy.
• Only one anastomosis is required compared to the Duodenal Switch and the Gastric Bypass where a second anastomosis is required. This decreases the risk of internal hernias.
• Great procedure for patients with BMI > 50, and also for patients with Diabetes.

Cons:

• Malodorous stool or gas may occur
• In order to avoid vitamin deficiencies and malnutrition which can be a result of the Loop Duodenoileostomy, patients are placed on a daily vitamin regimen. The risk is less than with the Duodenal Switch since there is a longer segment of intestine to absorb nutrients.